Provider Demographics
NPI:1588684625
Name:CLARK, CHARLES PATRICK (CRNA)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:PATRICK
Last Name:CLARK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1084 THOMPSON RD
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:NC
Mailing Address - Zip Code:28734
Mailing Address - Country:US
Mailing Address - Phone:828-369-9187
Mailing Address - Fax:
Practice Address - Street 1:120 RIVERVIEW ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:NC
Practice Address - Zip Code:28744
Practice Address - Country:US
Practice Address - Phone:828-524-8411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2009-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC151205163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP00289782OtherRAILROAD MEDICARE
GA986074426AMedicaid
NC8052336Medicaid
GA986074426AMedicaid